Athletic Pubalgia (Sports Hernia)

Spilios A. Pappas, MD
The Operative Review of Surgery. 2023; 1:318-321.

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Table of Contents

Pathophysiology and Presentation
Diagnosis and Treatment

References

Pathophysiology and Presentation

Also Known as “Sports Hernia”, “Sportsman’s Hernia”, “Athletic Hernia”, “Gilmore’s Groin”, “Hockey Groin”, “Core Muscle Injury”, or “Inguinal Disruption”

Basics

  • Definition: Chronic Groin Pain (> 6-8 Weeks) without a Demonstrable Hernia in the Setting of Frequent Athletic/Strenuous Activity
    • Not a True Hernia
  • From Chronic-Repetitive Trauma/Stress to the Groin
  • Most Common in High-Intensity Sports – Rugby, Football, Hockey, and Soccer 1-4
    • Can Occur Even with Low-Intensity Activity

Causes 5-9

  • Muscle Tears
    • Rectus Abdominis at the Distal Insertion
    • Transversalis Fascia of the Posterior Inguinal Wall
    • Conjoint Tendon at the Distal Attachment
    • External Oblique Aponeurosis
  • Nerve Impingement
  • Compartment Syndrome
  • Inflammation
  • *Incipient Hernia May Play a Role – Not Entirely Understood

Groin Hernias

Presentation 10-12

  • Presentation is Generally Nonspecific
  • Groin Pain with No Evidence of a Groin Hernia
  • Pain is Generally Activity Related and Resolves with Rest
  • Often Reproduced by Straining, Abdominal Crunches, Twisting, Valsalva, Coughing, or Sneezing

Normal Inguinal Canal 13

Diagnosis and Treatment

Diagnosis

  • Diagnosis is Clinical Based on History and Physical Examination
  • The Majority of Surgeons Will Order Diagnostic Imaging (MRI, US, or CT) Prior to Surgical Intervention
  • Other Similar Pathology to Rule Out: 5
    • Adductor Strain
    • Osteitis Pubis
    • Stress Fracture of the Femoral Neck or Pubic Rami
    • Femoroacetabular Impingement (FAI)

British Hernia Society 2014 Consensus Guidelines for Diagnosis 14

  • At Least Three of the Five:
  • 1. Pinpoint Tenderness Over the Pubic Tubercle at the Insertion of the Conjoint Tendon
  • 2. Palpable Tenderness Over the Deep Inguinal Ring
  • 3. Pain and/or Dilation of the External Ring with No Obvious Hernia Evident
  • 4. Pain at the Origin of the Adductor Longus Tendon
  • 5. Dull, Diffused Pain in the Groin, Often Radiating to the Perineum and Inner Thigh or Across the Midline

Treatment

  • Initial: Rest and Physical Therapy 4,5,15-18
    • Rest for 6-8 Weeks with Gradual Return to Activity
    • NSAIDs or Steroid Injections
    • Ice or Heat
    • Massage
  • If Fails: Surgical Repair

References

  1. Kachingwe AF, Grech S. Proposed algorithm for the management of athletes with athletic pubalgia (sports hernia): a case series. J Orthop Sports Phys Ther. 2008;38:768-781.
  2. Meyers WC, Foley DP, Garrett WE, Lohnes JH, Mandlebaum BR. Management of severe lower abdominal or inguinal pain in high-performance athletes. PAIN (Performing Athletes with Abdominal or Inguinal Neuromuscular Pain Study Group). Am J Sports Med. 2000;28:2-8.
  3. Nam A, Brody F. Management and therapy for sports hernia. J Am Coll Surg. 2008;206:154-164.
  4. Caudill P, Nyland J, Smith C, Yerasimides J, Lach J. Sports hernias: a systematic literature review. Br J Sports Med. 2008;42:954-964.
  5. Elattar O, Choi HR, Dills VD, Busconi B. Groin Injuries (Athletic Pubalgia) and Return to Play. Sports Health. 2016 Jul;8(4):313-23.
  6. Albers SL, Spritzer CE, Garrett WE, Jr, Meyers WC. MR findings in athletes with pubalgia. Skeletal Radiol. 2001;30:270-277.
  7. LeBlanc KE, LeBlanc KA. Groin pain in athletes. Hernia. 2003;7:68-71.
  8. Irshad K, Feldman LS, Lavoie C, Lacroix VJ, Mulder DS, Brown RA. Operative management of “hockey groin syndrome”: 12 years of experience in National Hockey League players. Surgery. 2001 Oct;130(4):759-64; discussion 764-6.
  9. Kumar A, Doran J, Batt ME, Nguyen-Van-Tam JS, Beckingham IJ. Results of inguinal canal repair in athletes with sports hernia. J R Coll Surg Edinb. 2002 Jun;47(3):561-5.
  10. Hackney RG. The sports hernia: a cause of chronic groin pain. Br J Sports Med. 1993;27:58-62.
  11. LeBlanc KE, LeBlanc KA. Groin pain in athletes. Hernia. 2003;7:68-71.
  12. Lovell G. The diagnosis of chronic groin pain in athletes: a review of 189 cases. Aust J Sci Med Sport. 1995;27:76-79.
  13. Gray H. Anatomy of the Human Body (1918). Public Domain.
  14. Sheen AJ, Stephenson BM, Lloyd DM, Robinson P, Fevre D, Paajanen H, de Beaux A, Kingsnorth A, Gilmore OJ, Bennett D, Maclennan I, O’Dwyer P, Sanders D, Kurzer M. ‘Treatment of the sportsman’s groin’: British Hernia Society’s 2014 position statement based on the Manchester Consensus Conference. Br J Sports Med. 2014 Jul;48(14):1079-87.
  15. Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J Sports Med. 2001;29:521-533.
  16. Farber AJ, Wilckens JH. Sports hernia: diagnosis and therapeutic approach. J Am Acad Orthop Surg. 2007;15:507-514.
  17. Nam A, Brody F. Management and therapy for sports hernia. J Am Coll Surg. 2008;206:154-164.
  18. Swan KG, Jr, Wolcott M. The athletic hernia: a systematic review. Clin Orthop Relat Res. 2007;455:78-87.
  19. Hammoud S, Bedi A, Magennis E, Meyers WC, Kelly BT. High incidence of athletic pubalgia symptoms in professional athletes with symptomatic femoroacetabular impingement. Arthroscopy. 2012;28:1388-1395.